Registration Form BIPOC Monthly Consultation
Please answer the questions below to register for the Monthly BIPOC Consultation virtual meeting.

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Email *
Consultation you are registering for: *
Full Name *
Phone Number *
License Type (LMFT, Psychologist, LCSW, LPC, Associate, etc.) & State (If you are a student/trainee, what license do you plan to obtain.) *
INFORMED CONSENT TO PARTICIPATE:

MEETING DETAILS:
First Tuesday of the Month at 12pm CST/10am PST
Consultation with Dr. Jenjee Sengkhammee
Virtual over Zoom Meeting 
I encourage cameras on to build community.

COST: $65. For payment you will receive an invoice from Square Reader on behalf of Heart and Mind Cultural Counseling and Training to pay with a credit card or you can Zelle payment to JTS & Me Moon Project, Inc. through the email jenjee@drjenjees.com. Payment is expected prior to participation in the meeting.

In the event that we will cancel the consultation you will receive a full refund.

REFUND POLICY / CANCELLATION INFORMATION
Receive a refund if you a.) cancel at least 72 hours in advance of the start time b.) 50% refund if you late cancel within 24 hours of the scheduled consultation. In lieu of cancellation fees I may be able to reschedule you for a future consultation.

A refund will be provided minus the $10 payment processing fee. No refunds provided at/after the time of the consultation meeting. To request a refund please email the host Jenjee Sengkhammee, @ drsengkhammee@gmail.com.

You will receive an email confirmation of your registration. One day prior to the meeting you will receive the Zoomlink. This information is for your use only and is not to be shared with anyone else. Thank you!

By clicking yes, you understand that you are registering for the Uplifting BIPOC Clinicians in Private Practice Consultation and agree to these terms.

*

The consultation meeting is designed to address your specific needs which may include questions about logistics of set up, how to run your private practice, business issues, practice policies, telehealth (working across state lines) clinical forms, insurance issues, ethical concerns, professional/career issues, and clinical issues, etc. 

If you have any specific questions you would like me to address in the consultation feel free to let me know in advance below:

Tell me if you need any accommodations to fully participate in the workshop.

A copy of your responses will be emailed to the address you provided.
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